Pain Assessment and Reassessment is required on each patient prior to pain medication administration and after pain medication administration. Reassessment should be completed 30 minutes after IV/IM medication administered and 1 hour after PO medication administered. Included are Meditech screen shots of the pain assessment and reassessment. Please contact your Regional Director of Clinical Operations with questions.

Pain assessment/reassessment

One of the many reasons to love Meditech....Health Information Exchange allows you to view patient information outside of your market from all HCA facilities and employed doctors offices. They are currently working on being able to view information from non-HCA. This is very helpful in day to day continuity of patinet care but most recently in the hurricaines when patients are transfered to different facilities.

Each facility choses the path, examples desktop icon, link in magic key menu etc. Please verify with your facility how to access. Included is an informational resource.

HIE

Every patient who enters a facility should have their allergies assessed and documented in Meditech. Please review the education below on allergy entry and adverse reactions.

Allergy Entry

Medication Reconciliation is a requirement for completion except for OR, Dialysis and CVOR areas of specialty. Included is a presentation reviewing the process of Medication Reconciliation. All parts apply to all specialties unless included in the exceptions below.  Contact your Regional Clinical Director of Operations for questions.  Thank you each for all you do!

Exceptions:

• Rehab- Needs everything above with the addition of the appendix 1

• Nursery and NICU- Part 7, 8 and 9 only

• Dialysis is exempt from the entire med rec education

• Actual OR and CVOR areas are exempt from the entire med rec education

***Day surgery, pacu and cath lab type areas still need all of the education like the inpatient units.

Med Rec Education

With the Meditech enhancement being so extensive, attached are some additional educational references specific to Restraint Documentation and Discharge Workflow Changes. Please contact your Regional Director of Clinical Operations with questions.

Restraint

DC Flowsheet

Discharge Enhancement

Protect yourself and your patients by assessing for and administering the flu vaccine. Please review the attached document highlighting the assessment, documentation, and administration of the flu shot for your patients.

Flu Education

Friendly Reminder: Flu shot documentation is due to HealthTrust by 10/31.

One of the goals of the Controlled Substance Safety Component of the 2018 Clinical Safety Improvement Program is to decrease the potential for patient misuse of prescribed opioids post-discharge. To work toward meeting that goal patients need to be educated on safe use, storage, and disposal of opioids. Please reivew the updated Teach/Educate intervention below and contact your Regional Director of Clinical Operations for questions.

Teach/Educate Intervention: Opioids

Did you know.....The Clinical Excellence blog has links to Atlas and Lippincott. Please feel free to use these sites for additional education and reference to policy. The links can be found on the top of the page.

SPOT is an application that monitors all patient labs and vitals in real time and uses the information to identify patients who are risk for sepsis.

Early identificaton = Early treatment.

I have attached an educational reference on SPOT. This training is included in annual update this year. Please reach out to your Regional Director of Clinical Operations for additional questions

SPOT Handout

Many of you have heard about the process changes the EHR Release Program is undergoing with the largest change combining provider documentation, nursing documentation (EBCD) and provider ordering for Inpatient and ED into a single release per quarter. All updates can be viewed in atlas.

Evidence-Based Clinical Documentation (EBCD) Regular Maintenance updates plus documentation enhancements for Moderate Sedation, Restraints, Discharge Instructions, and Vaccines and Regulatory updates for Inpatient Rehab.

Meditech 5.6.7 OE Includes updates to Restraints and new OE screens for Discharge, Discharge with Parameters, and Pediatric Asthma Severity Scoring Tool

Meditech 5.6.7 Discharge Includes updates to Discharge Plan, PDoc and EBCD Discharge documentation. Also includes new OE screens for Discharge and Discharge with Parameters with workflows for both Providers and Nursing.

Meditech 5.6.7 Restraints Includes updates to Restraint documentation in OE and EBCD to align with the corporate policy.

EBCD 2018.3 Provider Discharge Process (003)

EBCD 2018.3 Nursing without DC Restraints

EBCD 2018.3 Restraints Update (End User Education) (002)